Reducing Emergency Department Overutilization by Broadening Homelessness Services
Luke Morris
Cedars-Sinai Medical Center
Homelessness Figures
The ED Care Model
Problems at the Intersection
A New Role
Evidence of Effect
This author has no conflicts of interest to disclose
United States (~pop. 331.5 million)
580,466 People Experiencing Homelessness (PEH)
0.175% of U.S. population
California (~pop. 40 million)
161,548 PEH
0.408% of state population
California makes up 11.9% of U.S. pop, but hosts 28% of all PEH in U.S.
Figures via 2020 Census and HUD 2020 Annual Homelessness Assessment Report
LA County (~pop. 10 million)
25% of California’s population but 41% of its PEH
3% of U.S. population but 12% of its PEH
LA City (~pop. 3.9 million)
39% of county population by 62% of PEH
2/3 in first episode of homelessness
Estimated new 20,000 PEH amid COVID
Figures via LAHSA 2020 Count and Union Rescue Mission in Skid Row
A place for stabilization
Get you stable enough to go back home
or stable enough to transport to an inpatient unit
Problems with non-urgent utilization
Overburdens department resources
Increases wait for care for all patients
Chair reaction of patients Leaving before they’re even seen
Crowding and overflowing longstanding issues
Examples of low-acuity cases coming in
prescription refills
treatment of hypertension
chronic elevated blood sugar
behavioral health
Source of patient and staff harm
“COVID-19 has laid bare medicine’s house of cards.” *
* Dr. Sharon Anoush Chekijian in U.S. News and World Report | Graphic via CDC
7,956 visits by 3,194 PEH patients Feb 2020-Jan 2021
Roughly 2.49 visits per PEH patient
Many there for basic needs
Food
Shelter
Primary care-level treatment
Passed in 2018, requires hospitals to document info about patients experiencing homelessness before discharging them.
Services offered
Transportation
Meal
Meds
Vaccinations
Weather-appropriate clothing
Resources offered
Clinical/Behavioral
Follow-up with PCP
Help getting health coverage
Are CRCs effective at reducing the use of emergency services for non-urgent matters while ensuring that homeless patients can access their basic needs?
Data gathered in fulfilling SB1152 needs used to measure role’s impact
Diff-in-diff cohort model
Visit rates of patients experiencing homelessness
Split by whether they were seen by a CRC during their index visit
Dependent variables
Time interval between visits (in days)
Cost of stay
Length of stay (LOS)
Differences in the populations were tested for statistical significance using a Welch’s t-test
A two-sample t-test demonstrated statistical significance (p = 0.0014)
22.82% increase to # of days elapsed before a patient returned to the ED after visiting with a CRC
95% confidence interval: 2.6-10.9 days larger gap between ED visits
Revisit rate:
⬇️35%
95% CI:
0.8-1.4 fewer visits
p: <0.0001
Revisit rate:
⬇️35%
95% CI:
1.1-2.1 fewer visits
p: <0.0001
Difference in cost of care
p = 0.1050
Not statistically significant
Difference in length of stay in the ED
p = 0.0150
Not statistically significant
Makes sense considering CRC can’t really affect those figures
Increased gap between ED visits
Lowered rate of ED visits over 90 and 180 days
Implications
Increased utilization of community resources may be decreasing frequency of needs that draw patients experiencing homelessness to ED
Reduced burden by lower-urgency needs on ED resources
Possible effects
Shorter wait times
Fewer patients leaving without being seen
Greater focus on other patients with more acute needs
Slides so far showed Feb 2020-Jan 2021, but the work continues.
Results Feb 2020-Jun 2022
⬆️ by 5.2-16.6 days
⬇️ by 0.7-1.2 visits
⬇️ by 1.0-1.8 visits